不阻断肝血流在原发性肝癌肝切除术中的应用

目的探讨原发性肝癌患者行肝切除术中不阻断肝血流对肝功能及术后恢复的影响。方法将2010年6月-2013年6月福建省立医院收治的80例行肝切除术的原发性肝癌患者依据肝血流阻断方法的不同分为3组:第一肝门阻断组(Pringle组,n=24)、半肝血流阻断组(HVC组,n=24)及不阻断肝血流组(n=32)。分别比较不阻断肝血流组与Pringle组和HVC组患者的手术时间、术中出血量、术后肝功能变化、手术并发症及术后住院时间。计量资料和计数资料分别采用方差分析及卡方检验,方差分析中多重比较采用Dunnett-t检验。结果 3组患者手术时间、出血量差异均无统计学意义(F值分别为2.45,0.34,P值均0.05)。术后1及7 d血清TBil及ALT恢复情况,不阻断肝血流组[1 d,TBil:(22.4±9.4)μmol/L,ALT:(287.4±165.7)U/L;7 d,TBil:(17.1±6.6)μmol/L,ALT:(86.2±54.5)U/L]优于Pringle组[1 d,TBil:(33.5±11.9)μmol/L,ALT:(429.5±137.8)U/L;7 d,TBil:(24.5±7.0)μmol/L,ALT:(145.5±43.6)U/L]及HVC组[1d,TBil:(29.1±8.3)μmol/L,ALT:(390.2±176.6)U/L;7 d,TBil:(21.5±7.5)μmol/L,ALT:(121.5±56.8)U/L](P值均0.05)。血清Alb恢复情况,术后1 d,不阻断肝血流组[(29.3±2.8)g/L]优于Pringle组[(27.3±3.3)g/L](P值均0.05),但与HVC组[(27.8±2.5)g/L]相比,差异无统计学意义(P0.05);术后7 d,3组患者差异均无统计学意义(P值均0.05)。不阻断肝血流组术后住院时间[(10.3±2.1)d]较Pringle组[(12.7±2.6)d]和HVC组[(12.0±2.2)d]显著缩短(P值均0.05)。结论不阻断肝血流较第一肝门阻断、半肝血流阻断,不增加手术时间及术中出血量,且具有肝损伤较轻及术后恢复快的优点。     

选择性第一肝门阻断行肝癌切除84例报告

目的:探讨选择性第一肝门阻断行肝部分切除术的临床应用。方法:同期比较在选择性第一肝门阻断和第一肝门完全阻断条件下,分别行肝部分切除术的术后并发症及肝功能恢复情况。结果:84例原发性肝癌行选择性第一肝门阻断肝部分切除术。其中,右半肝血流阻断24例,右肝前叶血流阻断10例,右肝后叶血流阻断6例,左半肝血流阻断28例,左肝外叶血流阻断16例。全组肝实质离断时间为(20.9±5.6)分钟,出血量为(410.8±105.2)ml,术后ALT峰值为(312.5±110.4)U/L,总胆红素峰值为(26.8±9.6)μmol/L,肝功能恢复时间为(7.3±3.1)天。同期行第一肝门完全阻断肝部分切除术88例,肝离断时间为(14.8±7.6)分钟,出血量为(456.3±125.6)ml,术后ALT峰值为(860.6±108.2)U/L,总胆红素峰值为(53.1±29.8)μmol/L,肝功能恢复时间为(13.5±5.7)天。两组病例均元围手术期死亡,无肝衰、胆汁漏、腹腔内感染及大出血等严重并发症。结论:选择性第一肝门阻断肝部分切除术保留了健侧肝脏的正常血供,术后肝功能损害轻,恢复快,特别适用于肝癌并肝硬化的病例。该方法安全、简单,有推广应用价值。     

Pringle法与肝下下腔静脉阻断联合Pringle法在肝脏巨大血管瘤切除术中的应用效果评价

目的评价两种不同的入肝血流阻断方式在肝脏巨大肝血管瘤切除术中的应用效果。方法选取2008年1月-2014年12月于天门市中医医院住院的肝脏巨大血管瘤患者20例,将其分为A、B两组,每组10例。A组采用Pringle法进行肝血流阻断,B组采用肝下下腔静脉阻断联合Pringle法阻断入肝血流。比较两组患者的手术时间、肝门血流阻断时间、术中出血量、输血率以及术后肝功能指标。计量资料组间比较采用t检验,计数资料组间比较采用Fisher精确检验。结果两组患者手术时间、肝门血流阻段时间比较,差异均无统计学意义(P值均0.05);B组患者的术中出血量、输血量及输血率明显低于A组,差异均有统计学意义(P值均0.05);与A组相比,B组患者术后第3天及第7天的ALT、AST及TBil水平均较低,差异均有统计学意义(P值均0.05);两组术后并发症发生率差异均无统计学意义(P值均0.05)。结论肝下下腔静脉阻断联合Pringle法阻断入肝血流在巨大血管瘤切除术中不仅能够减少术中失血量,而且有利于患者术后肝功能的恢复,值得在临床上推广应用。     

半肝血流阻断法与肝门阻断法在肝切除术中的应用效果比较

目的探讨不同血流阻断方案在原发性肝细胞癌患者手术中的效果,为肝切除术中最佳血流阻断方式的选择提供参考。方法回顾性分析2010-06~2017-06肝细胞癌行开腹肝部分切除患者78例,按手术中肝血流阻断方式分为两组:A组(半肝血流阻断)40例,B组(Pringle法肝门阻断)38例。对两组患者手术时间、术中出血量、术中血流阻断时间、术后血清丙氨酸转氨酶水平、术后早期并发症情况进行比较。结果A组中位手术时间为160.5 min,中位失血量为498.2 ml,中位血流阻断时间为33.7 min,B组依次为155.3 min、512.0 ml和31.6 min,两组差异无统计学意义(P0.05)。A组术后第1天、第3天、第7天的丙氨酸转氨酶水平低于B组(P0.05)。A组发生术后并发症5例(12.5%),其中胆瘘1例,肝断面出血1例,胸腔积液2例,切口感染1例。B组发生术后并发症8例(21.1%),其中胆瘘2例,胸腔积液3例,大量腹水3例。两组术后早期并发症发生率比较差异有统计学意义(P0.05)。结论半肝血流阻断法较传统Pringle法肝门阻断法在原发性肝细胞癌患者手术中可以减轻术后肝功能损害,降低并发症发生率,是肝癌肝切除术中一种安全、有效的血流控制方法,值得临床推广应用。     

SHVE在规则性肝切除术中的应用

56例肝切除术患者分为半肝血流阻断术组（P组）、选择性阻断入肝和出肝血流（SHVE）组（S组）,比较两组手术时间和术中出血量,术后肝功能的恢复以及术后并发症。结果：P、S组手术时间无显著性差异（P〉0．05）,术中出血量分别为617ml、426n11（P〈0．05）,S组术后3d和6d的血清谷丙转氨酶（ALT）水平显著低于P组,白蛋白水平显著高于P组（P〈0．01）;P组术后并发症显著高于S组。认为SHVE可将病侧肝脏与体循环进行有效隔离,防止健侧肝脏缺血再灌注损伤,肝外控制肝静脉,不阻断下腔静脉,全身血流动力学稳定,是一种安全、有效的肝血流阻断技术。     

间歇性全入肝血流阻断与区域性入肝血流阻断腹腔镜肝切除术治疗原发性肝癌患者术后恢复研究*

目的 探讨采取间歇性全入肝血流阻断与区域性入肝血流阻断腹腔镜肝切除术(LH)治疗原发性肝癌(PLC)患者术后恢复情况。方法 2016年3月～2021年3月我院诊治的128例PLC患者,均接受LH手术治疗,其中57例在术中采取间歇性全入肝血流阻断法,另71例采取区域性入肝血流阻断法。监测平均动脉压(MAP)和心率(HR),使用多普勒超声检测门静脉血流速度(PVV)。结果 区域血流阻断组术中出血量和肝血流阻断时间分别为(305.4±58.6)mL和(0.0±0.0)min,显著少于或短于全肝血流阻断组【分别为(382.5±60.3)mL和(24.2±7.5)min,P＜0.05】;在术后7 d,区域血流阻断组血清总胆红素水平为(16.4±8.5)μmol/L,血清白蛋白水平为(35.6±5.3)g/L,与全肝血流阻断组【分别为(25.7±7.2)μmol/L和(32.4±4.9)g/L】比,差异显著(P＜0.05);区域血流阻断组MAP、HR和PVV分别为(85.6±2.3)mmHg、(78.7±8.3)次/min和(20.3±0.2)cm/s,与全肝血流阻断组【分别为(86.8±2.5)mmHg、(79.6±8.1)次/min和(20.1±0.3)cm/s】比,差异无统计学意义(P＞0.05);术后,区域血流阻断组腹腔内出血、胆汁漏、胸腔积液和肺部感染发生率分别为1.4%、8.5%、14.1%和5.6%,与全肝血流阻断组(分别为3.5%、10.5%、22.8%和10.5%)比,差异无统计学意义(P＞0.05)。结论 采取区域性入肝血流阻断LH治疗PLC患者有较好的手术和术后恢复效果,能够有效降低术中出血量,减少肝血流阻断时间,减轻术后肝功能损伤。     

半肝血流阻断法用于肝切除术效果观察

目的探讨半肝血流阻断法下行肝切除术的效果及安全性。方法将87例患者随机分为观察组33例和对照组52例,两组分别于半肝血流阻断、全肝血流阻断下行肝切除术,观察两组手术情况及手术前后肝功能指标变化。结果两组均无术后死亡、出血量无明显差别;观察组肝血流阻断时间明显长于对照组,并发症发生率显著低于对照组,术后血清谷丙转氨酶（GPT）、胆红素显著低于对照组,血清白蛋白、胆碱脂酶显著高于对照组（P均〈0．05）。结论半肝血流阻断法用于肝切除术安全、有效,尤适用于术前肝功能欠佳或合并有肝硬化者。     

肝切除术后早期应用生长抑素对门静脉血流动力学的影响

目的:探讨肝切除术后早期应用生长抑素对门静脉血流动力学的影响及可能机制.方法:将32只健康家兔随机分为:A组(正常对照组)、B组(生理盐水治疗组)和C组(生长抑素治疗组). 对A组建立门静脉置管动物模型;B组和C组均建立50%肝切除及门静脉置管动物模型, 并于术中及术后早期分别滴注生理盐水和生长抑素. 定期(0.5、1、2 h)检测上述3组动物模型门静脉压力差值, 用超声多普勒检测动物模型门静脉血流方向、血管内径、截面积、平均血流速率及血流量, 同时检测动物模型肝功能变化.结果:动物模型在肝切除术后门静脉压力升高, 与A组相比, B组门静脉压力升高幅度明显高于C组(0.5 h:436.001±169.654 Pa vs258.012±167.497 Pa, P<0.05; 1 h:394.324±163.182 Pa vs 224.767±164.653 Pa, P<0.05; 2h:193.092±154.356 Pa vs 351.861±183.579Pa, P<0.05). 术中及术后早期检测A、B、C 3组动物门静脉血管内径和截面积无明显差异,但C组门静脉平均血流速率及血流量显著低于A组和B组(均P<0.001). 肝切除术后2 h, B组与C组间ALT、AST差异无显著意义.结论:肝部分切除术后, 早期应用生长抑素可降低门静脉压力的升高幅度, 这种作用可能与生长抑素降低了门静脉血流速率和血流量相关.     

保留半肝动脉血供的入肝血流阻断法对大鼠肝缺血再灌注损伤的影响

目的:探讨保留半肝动脉血供的入肝血流阻断法对大鼠肝血缺再灌注损伤的影响.方法:将96只Wistar大鼠随机分为Pringle法Ⅰ组、半肝阻断Ⅱ组和保留半肝动脉血供的入肝血流阻断Ⅲ组.阻断肝血流30 min后,去血管夹恢复血流,分别于再灌注后1,2,6,24 h,抽血检测ALT和AST水平,然后取肝组织用于检测肝脏超氧化物歧化酶(SOD)及丙二醛(MDA)含量、肝脏病理学及肝细胞凋亡.结果:与Ⅰ组比较Ⅱ组和Ⅲ组再灌注后各时间点,ALT,AST,肝组织MDA含量及细胞凋亡率显著降低,肝组织SOD活力明显升高.Ⅲ组肝功改变、肝组织MDA含量、SOD活力及肝细胞凋亡率与Ⅱ组之间无显著差异(P>0.05).结论:保留半肝动脉血供的入肝血流阻断法对肝脏缺血再灌注损伤轻,效果好,操作简单,因而优于半肝血流阻断法.     

简易次全半肝血流阻断在肝部分切除术中的应用

目的探讨简易次全半肝血流阻断切肝术临床价值及可行性。方法将2009年2月～2010年10月行肝切除32例患者分为简易次全半肝血流阻断组（研究组）和第一肝门阻断组（对照组）,回顾分析2组患者术中出血量、手术时间、术后肝功能恢复及术后并发症。结果 2组患者手术时间和切肝中、切肝后出血量无显著差异,但2组肝功能恢复、并发症发生率差异有统计学意义。结论简易次全半肝血流阻断切肝术较第一肝门阻断有利于肝功能恢复,减少术后并发症的发生,为肝脏手术提供了一种安全、可行的方法。     

Hepatic blood inflow occlusion without hemihepatic artery control in treatment of hepatocellular carcinoma

AIM:To investigate the clinical significance of hepatic blood inflow occlusion without hemihepatic artery control (BIOwHAC) in the treatment of hepatocellular carcinoma (HCC).METHODS:Fifty-nine patients with HCC were divided into 3 groups based on the technique used for achieving hepatic vascular occlusion:group 1,vascular occlusion was achieved by the Pringle maneuver (n=20);group 2,by hemihepatic vascular occlusion (HVO) (n=20);and group 3,by BIOwHAC (n=19).We compared the procedures among the three groups in term of operation time,intraoperative bleeding,postoperative liver function,postoperative complications,and length of hospital stay.RESULTS:There were no statistically significant differences (P > 0.05) in age,sex,pathological diagnosis,preoperative Child’s disease grade,hepatic function,and tumor size among the three groups.No intraoperative complications or deaths occurrred,and there were no significant intergroup differences (P > 0.05) in intraoperative bleeding,hepatic function change 3 and 7 d after operation,the incidence of complications,and length of hospital stay.BIOwHAC and Pringle maneuver required a significantly shorter operation time than HVO;the difference in the serum alanine aminotransferase or aspartate aminotransferase levels before and 1 d after operation was more significant in the BIOwHAC and HVO groups than in the Pringle maneuver group (P < 0.05).CONCLUSION:BIOwHAC is convenient and safe;this technique causes slight hepatic ischemia-reperfusion injury similar to HVO.     

Hyperamylasemia after hepatic resection

BACKGROUND/AIMS: Hyperamylasemia often occurs after hepatectomy, but the detailed mechanism of this phenomenon remains unclear. The aim of this study was to analyze factors that may be associated with the development of hyperamylasemia following hepatic resection. METHODOLOGY: The Pringle maneuver was performed in 12 patients (Pringle group), the hemihepatic vascular occlusion technique in 11 patients (Hemihepatic group). RESULTS: In the Pringle group, postoperative serum amylase levels were elevated significantly in comparison with the preoperative levels, but were not elevated in the hemihepatic group. CONCLUSIONS: It is suggested that portal congestion by portal triad interruption carries a potential risk of serum amylase elevation and pancreatitis after hepatectomy.     

Successful intermittent application of the Pringle maneuver for 30 minutes during human hepatectomy: a clinical randomized study with use of a protease inhibitor

BACKGROUND/AIMS: There is experimental evidence that the liver can safely tolerate a cycle involving application of the Pringle maneuver for 30 minutes each time. METHODOLOGY: One hundred and twenty patients who underwent elective hepatectomy were randomly assigned to two groups of intermittent occlusion (30-min or 15-min Pringle group, n=60 each). A synthetic protease inhibitor (gabexate mesilate, GM, 2 mg/kg/h) was administered to pharmacologically alleviate visceral congestion, accompanied by hepatic pedicle clamping. Intraoperative data, liver function parameters and portal plasma levels of the inflammatory cytokine, interleukin (IL)-6 (a marker reflecting the status of visceral congestion), were examined as well as the postoperative course. Additionally, ten more patients randomly underwent right hepatectomy without GM, in order to clarify the influence of this agent on the present outcomes. RESULTS: The two groups of patients were comparable in terms of preoperative assessments, hepatic inflow occlusion time, extent of resection and background liver conditions. The 30-min Pringle group showed less blood loss during surgery (p=0.02) with a tendency for better postoperative mortality and morbidity. The postoperative liver functions were similar between the two groups. The portal plasma levels of IL-6 during pedicle clamping did not differ significantly between the two groups. When GM was not used, the 30-min intermittent Pringle maneuver induced a two-fold rise in serum transaminase levels on day 1 compared with the 15-min group. CONCLUSIONS: Our study indicates that intermittent application of the Pringle maneuver for 30 minutes each time can be accomplished effectively and safely for human hepatectomy, when combined with use of a protease inhibitor.     

Evaluation of total hepatic vascular exclusion and pringle maneuver in liver resection

BACKGROUND/AIMS: The effects of total hepatic vascular exclusion and Pringle maneuver on intraoperative course and postoperative recovery were retrospectively studied. METHODOLOGY: Records of 42 patients who underwent a major hepatectomy and six who had a minor hepatectomy were reviewed. Patients with chronic liver disease or obstructive jaundice were excluded. Hepatic vascular exclusion was used in 5 patients who were at high risk for back flow bleeding from the hepatic veins. Pedicular clamping was used in the other 43 patients. Intergroup differences in intraoperative blood loss, postoperative liver function, the serum interleukin-6 concentrations, and clinical outcome were compared. RESULTS: In four patients of the hepatic vascular exclusion group (n = 5), intraoperative blood loss was less than 2000 mL, and 6000 mL in the remaining patient. However the hepatic vascular exclusion group had longer hepatic ischemia time (45.2 +/- 10.3 min vs. 30.6 +/- 10.9 min), a greater blood loss (2304 +/- 2106 L vs. 913 +/- 1130 mL), a higher serum interleukin-6 concentration (347 +/- 320 pg/mL vs. 93 +/- 58 pg/mL), and a higher morbidity rate (80 vs. 7.1%) compared with the pedicular clamping group (n = 43) (P < 0.05). Postoperative liver function tests were comparable, and no patient developed postoperative hepatic failure. In the pedicular clamping group, intermittent pedicular clamping with periods of 15 minutes (n = 12) increased blood loss (662 +/- 421 mL vs. 1427 +/- 1890 mL), but did not reduce serum interleukin-6 concentration, liver cell damage, or morbidity rate postoperatively, compared with continuous or intermittent clamping of longer periods. CONCLUSIONS: Hepatic vascular exclusion is an effective way to limit blood loss in hepatic resection without causing sever liver injury. However, the interleukin-6 production is increased and the morbidity rate is high. Paradoxically, periodic release of pedicular clamping increases the blood loss but does not reduce liver cell injury or interleukin-6 production.     

Continuous normothermic hemihepatic vascular inflow occlusion over 60 min for hepatectomy in patients with cirrhosis caused by hepatitis B virus

Aim: To evaluate the safety of remnant liver in cirrhotic patients who had undergone irregular hepatectomy with continuous normothermic hemihepatic vascular inflow occlusion for over 60 min. Methods: A group of 133 cirrhotic patients who had hepatitis B virus accompanied by hepatocellular carcinoma and had undergone irregular hepatectomy by hemihepatic vascular inflow occlusion was studied. According to the time of hemihepatic vascular inflow occlusion, patients were assigned either to the control group, treatment(60) group, or treatment(90) group. The quantity of blood loss and blood transfusion, routine liver biochemistry and postoperative complications were retrospectively analyzed. Results: The data showed that there were no significant differences in postoperative complications between the three groups. Compared to the preoperative day, the levels of aspartate transaminase (AST), alanine transaminase (ALT), prothrombin time (PT) and serum bilirubin on postoperative days 1 and 3 were significantly increased in all three groups and the levels of albumin and platelet were significantly decreased on postoperative day 1. Duration of hospital stay and the levels of ALT and AST on postoperative days 1, 3 and 7 were higher in the treatment(90) group than in the control group and treatment(60) group (P < 0.05). However, no significant differences were displayed in the length of hospital stay and the levels of AST, ALT, PT, albumin, platelet count and serum bilirubin on postoperative days 1, 3 and 7 between the control group and the treatment(60) group (P > 0.05). Conclusion: Hemihepatic vascular inflow occlusion over 60 min is a possible method for irregular hepatectomy in patients with cirrhosis caused by the hepatitis B virus. However, caution must be exercised in utilizing this method where the time of vascular occlusion is over 90 min.     

不同肝血流阻断方案对手术切除原发性大肝癌患者治疗效果比较

目的 探讨不同肝血流阻断方法对外科手术切除原发性大肝癌患者疗效的影响。方法 2014年5月~2016年5月收治的172例原发性大肝癌患者,分别采用肝门阻断（n=52）、半肝阻断（n=44）和联合阻断（n=76）血流行肝癌切除术。结果 三组患者的基本资料比较差异无统计学意义（P>0.05）;三组血流阻断时间、手术用时和切除肝量差异均无统计学意义（P>0.05）,肝门阻断组出血量为（736.38±498.36） ml,显著多于半肝阻断组[（472.56±111.89） ml或联合阻断组的（356.14±132.53） ml,P<0.05],肝门阻断组输血量为（586.54±132.58） ml,显著多于半肝阻断组[（427.95±210.47） ml或联合阻断组的（184.38±72.54） ml,P<0.05];术后7 d,肝门阻断组血清ALT水平为（73.02±43.41） U/L,显著高于半肝阻断组[（55.89±40.82） U/L或联合阻断组的（52.01±33.81） U/L,P<0.05];三组手术并发症以肺部感染、切口感染、胆瘘、腹腔积液为主,但其发生率差异无统计学意义（P>0.05）;联合阻断组1 a生存率为96.1%,肿瘤复发率为2.6%,显著低于肝门阻断组的75.0%和15.4%或半肝阻断组的68.2%和20.5%（P<0.05）。结论 Pringle法联合肝下腔静脉阻断术阻断血流在切除原发性大肝癌患者外科手术过程中可以有效降低术中出血量,促进患者术后恢复,或许还能提高生存率。     

Effects of prior splenectomy on remnant liver after partial hepatectomy with Pringle maneuver in rats.

BACKGROUND/AIMS: In the case of the liver resection, the temporary occlusion of the hepatoduodenal ligament (Pringle maneuver) is often used. However, the maneuver causes hepatic ischemia/reperfusion (I/R) injury that strongly affects the recovery of patients. The present study investigated the effects of prior splenectomy on the remnant liver in partial hepatectomized rat with Pringle maneuver. METHODS: Pringle maneuver was conducted just before a two-thirds partial hepatectomy. Efficacy of splenectomy was assessed by survival rate, serum alanine aminotransferase (ALT), neutrophil infiltration into liver, recovery of remnant liver weight, and liver proliferating cell nuclear antigen (PCNA) levels. Ischemic preconditioning was performed as follows; 10 min of total hepatic ischemia followed by 10 min of reperfusion. RESULTS: In partial hepatectomized rats with 30 min of Pringle maneuver, seven out of 12 rats died within 3 days. On the other hand, when splenectomy was performed on 3 days before the maneuver, only one out of 12 rats died. When prior splenectomy was performed on eight and 18 days before the Pringle maneuver, respectively, similar efficacy was observed. In addition, prior splenectomy on 3 days before the maneuver showed that serum ALT activity, neutrophil infiltration, recovery of remnant liver weight, and PCNA levels in partial hepatectomized rats with Pringle maneuver were also ameliorated as compared with those of control rats without splenectomy. When effects of prior splenectomy were compared with those of ischemic preconditioning in these situations, efficacy of prior splenectomy was comparable with that of the ischemic preconditioning. CONCLUSIONS: Prior splenectomy ameliorated the I/R injury in the remnant liver after partial hepatectomy with Pringle maneuver. Effects of prior splenectomy may influence the liver for long duration, because splenectomy on 18 days before the maneuver still exerts effective action.     

The main indications and techniques for vascular exclusion of the liver

BACKGROUND: The purpose of vascular clamping during the course of liver resection is to reduce bleeding and subsequent complications. AIM: To show both step-by-step surgical techniques for vascular exclusion of the liver and their indications. METHODS: It is described the following techniques: clamping of the hepatic pedicle, "Pringle" maneuver; intermittent clamping of the hepatic pedicle; intermittent vascular exclusion of the liver, without vena cava clamping, and hepatic vascular exclusion with vena cava clamping. Also metabolic and homodynamic consequences as well as the technical failure of the application of each of them are discussed. CONCLUSIONS: The choice of technique to use for clamping during hepatectomy depends on the surgeon's judgment. Dogmatic or systematic attitude, is prejudiciable for the patient and liver surgeon must be able to use all kinds of clamping.